By Brian Paglia and Nick Watson

bpaglia@forsythnews.com, nwatson@gainesvilletimes.com

There was a pattern to most of the opioid addiction stories that Jim Goodson heard starting just over a decade ago.

An “average working stiff” would experience a traumatic injury and need surgery, usually related to the back. He would be prescribed powerful pain relievers, hydrocodone or oxycodone, but the patient would have a low pain tolerance and ask for more from his primary doctor.

After a while, the doctor would get uncomfortable and tell him to find a pain management practice. At the height of the medical field’s push to eliminate chronic pain in patients, the practice would continue the prescriptions.

“And there you go,” said Goodson, owner and pharmacist of Goodson Drug Co. in downtown Cumming.

That, Goodson said, epitomized the destructive side of the expanded use of opioid painkillers starting in the 1990s that led to the opioid epidemic.

The public is just now getting a closer look at the sheer number of opioid painkillers that flooded the country.

Between 2006 and 2012, Forsyth County received more than 27 million prescription pain pills, enough for 23 per person per year, according to a database published in July by The Washington Post and made available to the public.

In that same time frame, more than 76 billion opioid pills were distributed through pharmacies in the United States and more than 2.2 billion pills were distributed in Georgia.

The data comes from the Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System, which The Post gained access to as the result of a court order.

The data tracks the path of every opioid pain pill, from manufacturers and distributors to pharmacies, in every county and every state in the United States, providing “an unprecedented look at the surge of legal pain pills that fueled the prescription opioid epidemic, which resulted in nearly 100,000 deaths during the seven-year time frame ending in 2012,” according to The Post.

The Post made the data public “to promote a deeper understanding of the regional and local effects of the opioid crisis,” it said.

The emergency

What became a public health emergency started out of another.

In the late 1990s, about one-third of the U.S. population, or 100 million people, was affected by chronic pain. The medical field started to be more attentive to patient pain, making it the fifth vital sign. In response, drug companies and the federal government pushed for expanded use of opioid painkillers.

Opioids were originally designed to be prescribed for patients with some of the most serious injuries, according to Lisa Mize, the behavioral health inpatient coordinator for Northside Hospital, which has campuses in Atlanta, Canton and Cumming. But physicians started to prescribe opioids — particularly oxycodone and hydrocodone — for less serious reasons, Mize said, such as broken wrists, pulling wisdom teeth or high school sports injuries.

“They got focused on pain management and overprescribing hardcore medications recklessly,” Mize said.

In 2012, Northeast Georgia Health System, which has Hall County campuses in Gainesville and Braselton, changed its policy in the emergency department to a maximum three-day supply of opioid pain relief.

“We just knew that there was becoming an increasingly significant problem around opioids and addiction, I think, probably before the rest of the nation kind of learned it,” said Deb Bailey, executive director of government affairs at Northeast Georgia Medical Center.

In 2016, life expectancy decreased for Americans for the second straight year. Experts blamed the opioid epidemic. The increase in opioid use coincided with a rise in addiction and drug overdose-related deaths. 

In 2017, opioids were responsible for 47,600 deaths, according to the Centers for Disease Control and Prevention, accounting for more than two-thirds of all drug overdose deaths in the U.S. 

The crisis was even more pronounced in small towns, Mize said, where there was less oversight from regulators. Mom-and-pop pharmacies requested increasing amounts of opioid pills to fill prescriptions, more than was included in guidelines from big distributors like McKesson Corporation. The distributors simply changed the guidelines and delivered the pills, Mize said. Per-capita death rates soared in those areas.

“It’s destroyed towns,” Mize said.

Pharmacies were the gatekeepers, Mize said, but they had fewer ways to guard against abuse as the crisis was taking hold by 2010. 

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The pharmacies

In Forsyth County, where more than 27 million pills were received, almost 47% of them came to two pharmacies: Goodson Drug Co., and Lakeside Pharmacy & Compounding Lab, putting both among the top 15 in Georgia, according to the data.

Goodson Drug Co., received more than 7.6 million opioid pills from 2006 to 2012, the third highest amount in Georgia during that time period, according to The Post’s data.

Goodson wasn’t surprised to find his pharmacy so high on the list.

The company, which opened in 1959, has handled a high volume of prescriptions overall for decades, he said. One year, during the seven-year time frame of The Post’s data, Goodson Drug Co., was ranked the No. 1 pharmacy in the country for volume by Drug Topics magazine, Goodson said.

“We’re naturally going to be (high on the list),” Goodson said. “I don’t defend anything, but that’s the way it is.”

Goodson said much of that volume can be attributed to the pharmacy’s long history in Forsyth. It serves three generations of customers, Goodson said, but also serves several nearby hospices, nursing homes and small group homes with cancer patients who are often prescribed opioids “to comfort them as they go out,” he said.

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Lakeside Pharmacy owner Dr. Apollon Constantinides wasn’t surprised to see his pharmacy so high on the list, either. The pharmacy is located in Northside Hospital’s Forsyth County campus. He said that explains why Lakeside received almost 5 million opioid pills from 2006 to 2012, the 15th highest in Georgia during that time frame.

“I’ve got two cancer centers above me,” Constantinides said. He added, “We’re in the epicenter of this kind of stuff.”

Constantinides said pharmacies have discretion to fill prescriptions, and experience was the best training for how to “pick out someone who’s abusing their medication.”

It became commonplace to get customers with a driver’s license from Kentucky or Ohio whose doctor was in Florida but came to Lakeside to fill a prescription.

“I couldn’t tell them no fast enough,” Constantinides said. “... There’s plenty of places where that can be filled. There’s nothing good that can come of that.”

The best method a pharmacy had to prevent a prescription being abused was a pharmacist’s intuition, Goodson said.

“Back in the late ’50s, early ’60s, if you had a prescription … you’d take that thing and look at it and scrutinize it. You might even call the doctor if you were familiar with them,” Goodson said. “And that was it.”

Citizens Pharmacy, at 4.5 million, topped the list in Hall County and was 19th in the state for number of pills received.

Former Citizens Pharmacy owner Sammy Brown wrote in an email that the pharmacy dispensed more than 23.3 million dosages of all categories of medication between 2006 and 2012. That would mean 19.3% of all dosages dispensed were oxycodone or hydrocodone.

“It was our impression that the provider was treating the patient for a true and legitimate medical purpose,” Brown said, adding that any impression of illicit use or forgery was turned away.

The Times reached out to Brown multiple times via email to ask follow-up questions, but Brown did not respond to these requests.

Samir Shah took over the business in 2015. When presented with the data, Shah said the information was “irrelevant to how I operate today.”

“If there was any sort of data dump today, I could confidently say, without any objective data, that we’re not on the top of that list,” he said.

Shah said if he filled 100 prescriptions a day, 20% would be controlled substances, according to his data. 

“The dispensing pharmacist is the person who has that control in their hands as far what they’re going to let out the door,” he said.

Shah said his focus with the business now is to supply medical equipment, such as lift chairs, diabetic shoe fittings and continuous positive airway pressure machines.

The solutions

Gradually, new measures were implemented to try to curb the opioid crisis.

Around 2013, Constantinides said his pharmacy began to use a new prescription drug monitoring program that tracked controlled substance prescriptions in an electronic database. The program allowed pharmacies to look up a customer’s prescription history if they had concerns.

The program started out as voluntary, but the Georgia General Assembly passed House Bill 249 in 2017 to require pharmacies and prescribers to register with and use the program.

“We’ve got more leeway to just choose not to sell [to patients] than we did several years ago,” Goodson said. “I think every pharmacist will tell you they turn down prescriptions every day.”

Citizens Pharmacy manager Tiffany O’Donnell said the state database has been a tremendous help.

“In the past, it was normally you had to call your buddy down the street, ‘Hey, watch out. This patient may not be correctly using a medication. This prescriber may not be prescribing appropriately.’ So it was all word of mouth ... it was a huge help,” she said.

Every time a prescription is filled, the pharmacist checks the database.

Since 2016, the program has collected data and published drug surveillance reports, generally showing a downward trend line in terms of patients, pills and several other categories.

There were 2.33 million opioid patients in Georgia in 2016, a number that has fallen off by roughly 160,000 each year since.

At the county level, there were 719.8 opioid prescriptions in 2018 in Hall County per 1,000 people, and those with prescriptions had the drugs for roughly 19 days on average. That’s down from 865.5 in 2017 and 949.4 in 2016.

Communities also started to rally around the opioid epidemic with new partnerships emerging between local law enforcement agencies and community leaders.

The Forsyth County Drug Awareness Council formed in 2016 to advocate for and educate the community on drug and substance abuse. The Forsyth County Sheriff’s Office helped form the Johns Creek, Alpharetta, Forsyth County Drug Task Force in April 2018. The task force dedicated 18 narcotics agents to focus on dealer-level narcotic investigations in all three jurisdictions.

“We were very fortunate to have a law enforcement division here that took [the opioid crisis] seriously and was hands-on,” Constantinides said.

Similar work is being done in Hall, where the Partnership for a Drug Free Hall has in recent years brought together civic, law enforcement and health groups to focus on the opioid epidemic. 

The partnership, driven largely by Dallas Gay and Center Point’s director of substance abuse prevention Judy Brownell, has hosted a number of forums about how addiction works, the signs for families to watch and other options for pain management.

Dallas Gay is the grandfather of Jeffrey Dallas Gay Jr., a 21-year-old man who died of an overdose in 2012. A recovery center on Juanita Avenue in Gainesville was named in Jeffrey’s honor and opened earlier this year.

The alternatives

And the medical community is now emphasizing opioid alternatives for helping patients deal with chronic pain. 

Dr. Tennent Slack of Northeast Georgia Physicians Group approached Northeast Georgia Health System 18 months ago asking to create an independent practice focused on alternatives.

Slack, who started with NGPG in 2012 and has practiced medicine for more than 20 years, opened his non-opioid practice about eight weeks ago.

“When I first started in interventional pain, it very quickly became clear to me that I needed more tools, and the tools that we have available are just largely revolving around pharmaceuticals and steroid-based injections,” he said.

It’s taken years to learn more about alternative methods, which include regenerative injections, infrared light and nutrition. 

“Unfortunately, most alternative-type methods are not covered by insurance, so this was what I consider to be the devices and methods with the longest track record of efficacy and safety.”

Slack said he has tried to keep the price point reasonable so it is accessible to as many people as possible.

“Most of the people we see will have some kind of a musculoskeletal problem, whether it’s in a peripheral joint or the spine,” he said.

In response to the recent data release on opioid pain pills, Slack said it’s about time that attention has moved off of prescribers and onto the distributors and manufacturers, saying the prescribers have been “hammered for years.”

The overall trend for him and his prescribing colleagues has been fewer pills being requested over the past decade.

“A good doctor wouldn’t prescribe a pain pill if the patient weren’t asking for it, and I think this has helped the public understand that routinely asking for a pain pill may not be the best course of action,” he said.

More patients are wary of requesting an opioid prescription, and those that want them want the dosages to be tapered down.

“Before 2012 and certainly in the early 2000s, the patient almost felt like they had a right to get pain medication,” Slack said.

Northside has been asked to join the Colorado ALTO Project, a pilot program developed by the Colorado Hospital Association to develop strategies to increase the administration of opioid alternatives, Mize said.

“It’s about prevention, communities coming together to have responsible prescribing practices and alternatives to opioids,” Mize said. “It takes a community coming together to address all these things from all levels.”